Currentblue cross blue shield - louisianaPolicy AHS - G2159 - β - Hemolytic Streptococcus Testing

G2159: B-Hemolytic Streptococcus Testing

Defines coverage criteria and exclusions for laboratory testing to detect β-hemolytic streptococcal infections (throat, skin/soft tissue, serology, RADT, NAAT, culture) including indications (e.g., Centor score ≥3, absence of viral features), non-covered uses (screening, follow-up RADT, panels, simultaneous direct+amplification), and tests lacking evidence.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyG2159: B-Hemolytic Streptococcus Testing

Policy CodePolicy AHS - G2159 - β - Hemolytic Streptococcus Testing

Change TypeRevisions and removals (see policy update changes)

Effective DateFeb 1, 2026

Next Review Date

Key ActionProviders should document a modified Centor criteria score ≥3 or clinical suspicion of bacterial pharyngitis without viral features to justify throat culture testing; follow pediatric guidance for backup culture after negative RADT in children.

SourceLink

POLICY UPDATE CHANGES

02/01/2026 review: updated background, guidelines and references; removed CC2, CC5, CC6c, and CC10b from coverage criteria and removed CPT code 87040.

01/01/2025 review: updated CC6a to include nucleic acid testing as a follow-up test and added CPT code 86581.

03/10/2023: removed Note 2 and CPT code 83789 (coding enhancement).

05/15/2022: initial policy implementation.

MultipleCovered Indications

Coverage Summary

This policy, titled β-Hemolytic Streptococcus Testing (Policy No. AHS - G2159), is CURRENT and defines coverage criteria and exclusions for laboratory testing to detect β-hemolytic streptococcal infections (throat, skin/soft tissue, serology, RADT, NAAT, culture). The policy was originally effective 05/15/2022 and the current effective and last review date is 02/01/2026. It uses clinical indications (e.g., Centor scoring or absence of viral features), specific specimen types, and specialized serologic testing to determine when tests meet or do not meet coverage. Providers are instructed to document clinical rationale (for example, Centor scoring) and to follow pediatric backup-culture algorithms after negative RADT in children.

Centor threshold: the policy highlights a modified Centor (Centor) score of 3 or greater as a key threshold for recommending throat culture testing for suspected GAS pharyngitis.

Medical Necessity / Coverage Criteria

Medically Necessary / Meets Coverage Criteria

Covered when ALL of the following are met:

Throat/Respiratory indications

Bacterial culture testing from a throat swab for detection of a streptococcal infection causing respiratory illness when the individual has a modified Centor criteria score of 3 or greater
Bacterial culture testing from a throat swab when the individual is suspected of having bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea)
Bacterial culture testing from a throat swab following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent

Skin/soft tissue and invasive disease

In cases of skin and/or soft tissue infections, bacterial culture testing for a streptococcal infection from a skin swab or from pus MEETS COVERAGE CRITERIA
Positive culture from a normally sterile site (e.g., blood, synovial fluid, CSF) is considered definitive evidence of infection in the setting of a compatible clinical syndrome
From scientific background; supports culture as definitive

ARF / PSGN related testing

For individuals with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), serological titer testing MEETS COVERAGE CRITERIA
For individuals with suspected ARF or PSGN, Anti-streptolysin O (ASO) immunoassay MEETS COVERAGE CRITERIA
For individuals with suspected ARF or PSGN, Hyaluronidase activity or anti-hyaluronidase immunoassay MEETS COVERAGE CRITERIA
For individuals with suspected ARF or PSGN, Streptokinase activity or anti-streptokinase immunoassay MEETS COVERAGE CRITERIA

Not Medically Necessary / Does Not Meet Coverage Criteria

These tests or situations DO NOT MEET COVERAGE CRITERIA unless otherwise specified:

ANY of the following

RADT exceptions: RADT for a streptococcal infection does NOT meet coverage criteria except in symptomatic children under age three with a mitigating circumstance (including a symptomatic family member)
RADT follow-up exclusion: RADT does NOT meet coverage criteria as a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection
Updated to include nucleic acid testing as follow-up
RADT screening exclusion: RADT does NOT meet coverage criteria as a screening method in an asymptomatic patient (except as above for young children with mitigating circumstance)

Covered when ALL of the following are met

Coverage criteria as structured in policy sections (CC items referenced in revision history); this part documents changes mentioned in revision history (removals and additions).

ALL of the following

Allowed tests for ARF or PSGN
- Serological titer testing (e.g., rising or increased ASO or anti-DNase B titers)
- Anti-streptolysin O immunoassay (ASO)
- Hyaluronidase activity or anti-hyaluronidase immunoassay
- Streptokinase activity or anti-streptokinase immunoassay

Not covered / Does not meet coverage criteria

Policy sections specifying tests that do not meet coverage criteria in situations not described above.

ALL of the following

Serology exclusion restatement: For all situations not described above, serological titer testing DOES NOT MEET COVERAGE CRITERIA
ARF/PSGN immunoassay exclusion restatement: For all situations not described above, testing with an anti-streptolysin O immunoassay, a hyaluronidase activity or anti-hyaluronidase immunoassay, or a streptokinase activity or anti-streptokinase immunoassay DOES NOT MEET COVERAGE CRITERIA

Applicable Codes

Applicable CPT / HCPCS Procedure Codes (referenced in policy)CPT

86317	Immunoassay for infectious agent antibody, quantitative, not otherwise specified
86318	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method
86581	Streptococcus pneumoniae antibody (IgG), serotypes, multiplex immunoassay, quantitative
87070	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
87071	Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87081	Culture, presumptive, pathogenic organisms, screening only
87430	Infectious agent antigen detection by immunoassay technique; Streptococcus, group A
87650	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique
87651	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique

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1/2

Notable coding actions from the revision history: on 02/01/2026 the policy removed CPT code 87040. An earlier administrative coding adjustment removed CPT code 83789 on 03/10/2023. These removals are documented in the review/revision history.

Provider Actions / Billing Rules

Documentation Required

Document Centor score or clinical indication

Providers should document a modified Centor criteria score ≥3 or clinical suspicion of bacterial pharyngitis without viral features to justify throat culture testing; follow pediatric guidance for backup culture after negative RADT in children. Note: Centor ≥3 meets coverage threshold; for pediatric patients, if RADT is negative, collect backup culture per guidance.

Centor score ≥3
Pediatric backup culture after negative RADT

Documentation Required

Do not order simultaneous direct probe and amplification probe

Do not order both direct probe and amplification probe for the same organism in a single encounter; simultaneous ordering of direct probe and amplified probe for the same organism does not meet coverage criteria and may be denied.

Background & Evidence

β-hemolytic streptococci include Group A (GAS, Streptococcus pyogenes), Group B (GBS, Streptococcus agalactiae), and Groups C/G (GCS/GGS, Streptococcus dysgalactiae subsp. equisimilis). These organisms cause a spectrum of disease including pharyngitis (strep throat), scarlet fever, skin and soft tissue infections, invasive disease (e.g., bacteremia, necrotizing fasciitis), acute rheumatic fever (ARF), and post-streptococcal glomerulonephritis (PSGN).

Diagnostic modalities include bacterial culture (throat, blood, pus, skin swabs), which the CDC and the policy describe as the gold standard for throat culture; rapid antigen diagnostic tests (RADT) performed at point-of-care; nucleic acid amplification tests (NAATs/RNATs) including PCR and helicase-dependent amplification; and serologic testing (e.g., ASO, anti-DNase B, hyaluronidase, streptokinase) that reflect prior infection. Test performance varies: RADTs have variable sensitivity (summary sensitivity ~85.6% in children) with generally high specificity, while NAATs/RNATs show higher sensitivity (reported RNAT sensitivity ~97.5%) and are increasingly used in clinical settings.

Pediatric testing algorithms emphasize that children with Centor score ≥3 or without viral features may be tested, and that in children a negative RADT often requires follow-up culture or a more sensitive NAAT (a two-step algorithm with a backup throat culture or NAAT and mechanisms to notify families if backup culture becomes positive). Guidelines (CDC, AAP, IDSA) recommend limiting testing in children with obvious viral features and generally do not support routine testing in children under age three except in specific circumstances.

Definitions

Centor criteria: Centor consists of four components—tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough—each worth one point; a score of <3 makes GAS pharyngitis unlikely while a score of ≥3 indicates testing for GAS pharyngitis.

RADT (Rapid antigen diagnostic testing): RADTs detect streptococcal antigen at the point of care and have high specificity but variable sensitivity (summary sensitivity ~85.6% in pediatric meta-analyses); pediatric algorithms commonly require a backup culture or more sensitive NAAT when RADT is negative.

NAAT (Nucleic acid amplification test): NAATs amplify bacterial DNA/RNA (PCR, HDA, etc.); they are generally more sensitive than RADTs (RNAT sensitivity reported ~97.5%) and some are FDA-cleared for direct throat specimen testing; negative NAAT results typically do not require arbitration by a secondary test.

ARF (Acute rheumatic fever): ARF is a post-infectious, immune-mediated complication that can follow GAS pharyngitis (typically 2–4 weeks later); diagnosis relies on clinical criteria (Jones criteria) and laboratory evidence of antecedent GAS infection such as rising ASO or anti-DNase B titers, a positive throat culture, or a positive RADT.

PSGN (Post-streptococcal glomerulonephritis): PSGN is primarily due to GAS infection and presents with edema, hypertension, hematuria, and proteinuria; laboratory evidence of preceding GAS infection can include isolation from throat or skin or elevated streptococcal antibodies (e.g., ASO, anti-DNase B).

Revision History

2026-02-01revisedLatest

02/01/2026 review: updated background, guidelines and references; removed CC2, CC5, CC6c, and CC10b from coverage criteria and removed CPT code 87040. Detail: Literature review did not necessitate modifications to coverage criteria except listed removals. Highlight: material changes include removal of multiple CC items and removal of CPT code 87040.

2025-01-01revised

01/01/2025 review: updated CC6a to include nucleic acid testing as a follow-up test and added CPT code 86581. Detail: CC6a now reads: 'a) As a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection.' Highlight: material change adding NAATs to allowed follow-up testing and addition of CPT 86581.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyG2159: B-Hemolytic Streptococcus Testing

Policy CodePolicy AHS - G2159 - β - Hemolytic Streptococcus Testing

Change TypeRevisions and removals (see policy update changes)

Effective DateFeb 1, 2026

Next Review Date

SourceLink

On This Page

Prior Authorization

RADT and serology preauthorization implication

RADT and serological testing ordered outside of covered indications (for example, screening asymptomatic patients, RADT as a follow-up after culture or NAAT) do not meet coverage criteria and may be denied unless documentation supports an exception. Exception: RADT may be covered in symptomatic children under age three with a mitigating circumstance (including a symptomatic family member).

Screening asymptomatic patients
RADT as follow-up after culture or NAAT
Other serologic testing outside ARF/PSGN indications

Documentation Required

Laboratory evidence for ARF diagnosis

For suspected acute rheumatic fever (ARF), providers should obtain and document laboratory evidence of antecedent GAS infection. Acceptable evidence includes increased or rising ASO or anti-DNase B titers, a positive throat culture, or a positive rapid group A streptococcal antigen test. Required/related CPT codes: 86060, 86063, 86215.

Document rising or increased ASO/anti-DNase B titers
Or document positive throat culture or positive RADT/antigen test

Prior Authorization

Coverage limited to specified clinical scenarios

Serologic and specialized streptococcal immunoassays are covered only for patients with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN). For all other situations, these tests do not meet coverage criteria and may be denied.

Affected codes: 86060, 86063, 86215, 86317, 86318

05/01/2024 review: reorganized CC language for clarity; added CC4 for ARF/PSGN allowed tests and CC9 to note tests not allowed in other situations; former CC6 became CC7 stating serological titer testing does not meet criteria in other situations. Detail: Policy editorial changes and creation of specific CC items for ARF/PSGN and exclusions. Highlight: material reorganization creating new CC4 and CC9 and renumbering former CC6 to CC7.